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CME / ABIM MOC / CE

Is Bone Mineral Density Testing Underused in Prostate Cancer Care?

  • Authors: News Author: Pam Harrison; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 5/20/2022
  • Valid for credit through: 5/20/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for hematologists/oncologists, pathologists and laboratory medicine practitioners, internists, family medicine and primary care clinicians, physician assistants, nurses, and other members of the health care team for patients with prostate cancer.

The goal of this activity is that learners will be better able to describe dual-energy X-ray absorptiometry screening rates and their association with fracture rates among older men with prostate cancer initiating androgen deprivation therapy, based on a retrospective nationwide population-based cohort study using data from the Surveillance, Epidemiology, and End Results database and the Texas Cancer Registry linked to Medicare claims.

Upon completion of this activity, participants will:

  • Assess dual-energy X-ray absorptiometry screening rates and their association with fracture rates among older men with prostate cancer initiating androgen deprivation therapy, based on a retrospective, US nationwide population-based cohort study
  • Evaluate the clinical implications of dual-energy X-ray absorptiometry screening rates and their association with fracture rates among older men with prostate cancer initiating androgen deprivation therapy, based on a retrospective, US nationwide population-based cohort study
  • Outline implications for the healthcare team


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News Author

  • Pam Harrison

    Freelance writer, Medscape

    Disclosures

    Disclosure: Pam Harrison has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Stocks, stock options, or bonds: AbbVie (former)

Editor/Nurse Planner

  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC

    Disclosures

    Disclosure: Amanda Jett, PharmD, BCACP, has disclosed no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.


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CME / ABIM MOC / CE

Is Bone Mineral Density Testing Underused in Prostate Cancer Care?

Authors: News Author: Pam Harrison; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 5/20/2022

Valid for credit through: 5/20/2023

processing....

Clinical Context

Prostate cancer accounts for 26% of all new cancers in men. Among men receiving androgen deprivation therapy (ADT), risk is increased for fracture, which is linked to increased mortality. Extremely low rates of testing of bone mineral density (BMD), as recommended by recent guidelines, were found in a nationwide study of older men receiving ADT for the treatment of prostate cancer. The findings suggest that DXA screening is important to help prevent major fractures among older men with prostate cancer.

Study Synopsis and Perspective

"Androgen deprivation therapy (ADT) is the mainstay for treatment of locally advanced high-risk localized or metastatic prostate cancer [but it] can negatively impact bone health, resulting in decreased bone mineral density (BMD) and fractures," comment the researchers, led by Maria Suarez-Almazor, MD, PhD, from the University of Texas MD Anderson Cancer Center, Houston, Texas.

Even fewer men with Medicare Part D coverage who were at risk for fracture were being treated with a bone-modifying agent.

Although they found low rates of screening of BMD with a DXA (dual-energy X-ray absorptiometry) scans, use of such a scan "was associated with a lower risk of major fractures," they write.

This suggests that "DXA screening is important for the prevention of major fractures among older men with prostate cancer," they conclude.

The study was published online April 1 in JAMA Network Open.[1]

Fracture Risk

For their study, the team used data from the Surveillance, Epidemiology, and End Results database as well as the Texas Cancer Registry.

They identified 54,953 men (median age, 74 years) who had been diagnosed with localized or regional prostate cancer between January 2005 and December 2015.

Overall, only 7.9% of men had undergone DXA screening, although screening rates increased from 6.8% in 2005 to 8.4% in 2015.

Overall, 17.5% of men experienced a fracture after initial receipt of ADT; the median time to first fracture was 31 months. Some 7.7% of men experienced a major osteoporotic fracture.

Although DXA screening was not associated with fracture risk at any site, it was associated with a 9.1% lower risk for a major osteoporotic fracture, the authors note.

Some of the lowest rates of DXA screening were seen among Black men, as well as single men and those who had a full or partial state insurance buy-in, which is a proxy of socioeconomic status, the authors observe.

Higher rates of DXA screening were seen in men who had recently begun ADT, those who were older, those who had regional or high-grade disease, those who had previously had a fracture, those with known osteoporosis, and/or those with a higher Charlson comorbidity score.

Professional Society Guidelines Updated

The study ended in 2015; since then, nearly all professional society guidelines have been updated regarding the need for DXA screening, point out the authors of an accompanying editorial.[2]

"Thus, DXA screening rates in more recent years may be higher," suggest the editorialists, led by Amar Kishan, MD, from the University of California, Los Angeles.

In addition, the editorialists suggest that the fractures observed in this study "may be associated with skeletal metastases rather than osteopenia or osteoporosis that was not appropriately managed," because more than 70% of patients in this study had high-grade disease. Given that the median time to fracture was 31 months in the current study, "these fractures may have reflected progression events," they observe.

At the same time, this study highlights the fact that there is substantial room for improvement in evaluating men who receive ADT for bone health, the editorialists comment. "It is particularly problematic that low rates of DXA screening were identified among men who were non-Hispanic Black, single, or residing in areas with lower socioeconomic status and lower educational levels," they say.

The solution could be quite straightforward. However modest the association between DXA screening and major fracture risk was, "it is possible that a simple intervention, such as supplemental vitamin D and calcium, could optimize bone health," the editorialists comment.

"An increased rate of DXA screening among men receiving long-term ADT, along with appropriate use of bone-modifying agents...may meaningfully reduce the chance of osteoporosis-related fractures," they conclude.

The study was funded by the Texas Department of State Health Services and the CPRIT. Dr Suarez-Almazor reports receiving consulting fees from Avenue Therapeutics, Celgene, ChemoCentryx, Eli Lilly and Company, Gilead Sciences, and Pfizer. Dr Kishan reports receiving grants from the American Society for Radiation Oncology, the National Institutes of Health, the Prostate Cancer Foundation, the US Department of Defense, and ViewRay, as well as honoraria and consulting fees from Varian Medical System and ViewRay. He also owns shares in ViewRay.

JAMA Netw Open. Published online April 1, 2022.

Study Highlights

  • This retrospective nationwide population-based cohort study used data from the Surveillance, Epidemiology, and End Results database and the Texas Cancer Registry linked to Medicare claims.
  • Participants were 54,953 men aged at least 66 (median, 74; range, 66-99) years with prostate cancer diagnosed between January 2005 and December 2015 who began ADT.
  • Racial and ethnic composition was 8.5% Hispanic, 11.1% non-Hispanic Black, 75.4% non-Hispanic White, and 5.0% other.
  • Only 7.9% received DXA screening overall, with the screening rate increasing from 6.8% in 2005 to 8.4% in 2015.
  • Lower screening rates were linked to being single (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.81-0.97; P=.01) and non-Hispanic Black (OR, 0.80; 95% CI, 0.70-0.91; P<.001), living in small urban areas (OR, 0.77; 95% CI, 0.66-0.90; P=.001) and areas with lower educational levels (OR, 0.75; 95% CI, 0.67-0.83; P<.001) and higher state buy-in status (as a marker for poverty), and receiving nonsteroidal androgens (OR, 0.57; 95% CI, 0.39-0.84; P=.004).
  • Factors associated with higher DXA screening rates included older age, history of osteoporosis or fractures, more advanced or high-risk cancer, and more comorbidities.
  • There were also differences across states in DXA screening rates.
  • After initial receipt of ADT, 17.5% of patients overall developed fractures and 7.7% had a major osteoporotic fracture, with median time to first fracture of 31 months (interquartile range, 15-56 months).
  • Factors associated with time to first fracture included older age, single status, regional disease stage, high cancer grade, higher Charlson comorbidity score, full or partial state buy-in status, and receipt of at least 2 types of ADT.
  • Among men without previous fractures before receiving ADT, multivariable Cox proportional hazards model with propensity score adjustment showed that DXA screening was not associated with fracture risk at any site (hazard ratio [HR], 0.96; 95% CI, 0.89-1.04; P=.32).
  • However, after propensity score adjustment, previous DXA screening was associated with 9.1% lower risk for major osteoporotic fracture (HR, 0.91; 95% CI, 0.83-1.00; P=.05).
  • Only 3.1% of men received bone-modifying agents; those who underwent DXA screening were more likely to receive them (18.8%) than those who did not (1.8%).
  • Five-year overall survival was 74% among men who had a major fracture and 78% among men without fractures (P<.001).
  • The investigators concluded that rates of DXA screening, which is the standard of care for BMD assessment among patients with a high risk for osteoporosis, were low among older men with localized or regional prostate cancer after starting ADT.
  • Despite all men having access to Medicare insurance that covered DXA screening, there were demographic and socioeconomic disparities in screening rates.
  • Despite low screening rates, evaluation of BMD with DXA scanning shortly before or after ADT initiation was associated with lower risk for major fractures after adjustment for covariates.
  • In light of the harmful effect of fractures on prolonged immobilization, morbidity, and mortality, implementation strategies are needed to encourage uptake of bone health screening guidelines in clinical practice.
  • Early intervention with bone-modifying agents could potentially lower the burden of illness linked to fractures among older men who are prostate cancer survivors.
  • Study limitations include use of claims data, which could not eliminate the possibility that some fractures were metastatic rather than osteoporotic; and limited generalizability, as 89.7% of patients had localized disease and all were older than 65 years.
  • An accompanying editorial notes that recent DXA screening rates may be higher, as nearly all professional society guidelines were updated after study end, and that fractures in this study might reflect skeletal metastases rather than poorly managed osteopenia or osteoporosis.
  • Substantial improvement is needed in evaluating bone health in men receiving ADT, especially among non-Hispanic Blacks, single men, and residents in areas with lower socioeconomic status and education.
  • A simple intervention, such as supplemental vitamin D and calcium, combined with increased DXA screening and appropriate use of bone-modifying agents, could optimize bone health and reduce osteoporosis-related fractures.

Clinical Implications

  • Despite low screening rates, DXA scanning shortly before or after ADT initiation was associated with lower risk for major fractures.
  • The findings suggest that DXA screening is important to help prevent major fractures among older men with prostate cancer.
  • Implications for the Health Care Team: Given the harmful effect of fractures on prolonged immobilization, morbidity, and mortality, implementation strategies are needed to encourage uptake of bone health screening guidelines in clinical practice.

 

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